Kevin Liou

A meta-analysis of robotic vs . conventional mitral valve surgery

OBJECTIVES The present study is the first meta-analysis to compare the surgical outcomes of robotic vs. conventional mitral valve surgery in patients with degenerative mitral valve disease. METHODS A systematic review of the literature was conducted to identify all relevant studies with comparative data on robotic vs. conventional mitral valve surgery. Predefined primary endpoints included mortality, stroke and reoperation for bleeding. Secondary endpoints included cross-clamp time, cardiopulmonary bypass time, length of hospitalization and duration of intensive care unit (ICU) stay. Echocardiographic outcomes were assessed when possible. RESULTS Six relevant retrospective studies with comparative data for robotic vs. conventional mitral valve surgery were identified from the existing literature. Meta-analysis demonstrated a superior perioperative survival outcome for patients who underwent robotic surgery. Incidences of stroke and reoperation were not statistically different between the two treatment arms. Patients who underwent robotic surgery required a significantly longer period of cardiopulmonary bypass time and cross-clamp time. However, the lengths of hospitalization and ICU stay were not significantly different. Both surgical techniques appeared to achieve satisfactory echocardiographic outcomes in the majority of patients. CONCLUSIONS Current evidence on comparative outcomes of robotic vs. conventional mitral surgery is limited, and results of the present meta-analysis should be interpreted with caution due to differing patient characteristics. However, it has been demonstrated that robotic mitral valve surgery can be safely performed by expert surgeons for selected patients. A successful robotic program is dependent on a specially trained team and a sufficient volume of referrals to attain and maintain safety.

Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: Meta-Analysis of Clinical Outcomes and Cost-Effectiveness

OBJECTIVE Transcatheter aortic valve implantation (TAVI) has emerged as a feasible alternative treatment to conventional surgical aortic valve replacement (AVR) for high-risk patients with aortic stenosis. The present systematic review aimed to assess the comparative clinical and cost-effectiveness outcomes of TAVI versus AVR, and meta-analyse standardized clinical endpoints. METHODS An electronic search was conducted on 9 online databases to identify all relevant studies. Eligible studies had to report on either periprocedural mortality or incremental cost-effectiveness ratio (ICER) to be included for analysis. RESULTS The systematic review identified 24 studies that reported on comparative clinical outcomes, including three randomized controlled trials and ten matched observational studies involving 7906 patients. Meta-analysis demonstrated no significant differences in regards to mortality, stroke, myocardial infarction or acute renal failure. Patients who underwent TAVI were more likely to experience major vascular complications or arrhythmias requiring permanent pacemaker insertion. Patients who underwent AVR were more likely to experience major bleeding. Eleven analyses from 7 economic studies reported on ICER. Six analyses defined TAVI to be low value, 2 analyses defined TAVI to be intermediate value, and three analyses defined TAVI to be high value. CONCLUSION The present study demonstrated no significant differences in regards to mortality or stroke between the two therapeutic procedures. However, the cost-effectiveness and long-term efficacy of TAVI may require further investigation. Technological improvement and increased experience may broaden the clinical indication for TAVI for low-intermediate risk patients in the future.

Drug-eluting Balloon versus Second Generation Drug Eluting Stents in the Treatment of In-stent Restenosis: A Systematic Review and Meta-analysis

BACKGROUND In-stent restenosis (ISR) remains a significant mode of stent failure following PCI. The optimal treatment strategy, however, remains undefined and the role of drug-eluting balloons (DEB) in the management of ISR is also unclear. METHODS A meta-analysis was performed to compare the efficacy of DEB in the treatment of ISR against second generation drug eluting stents (DES). RESULTS Seven studies comprised of 1,065 patients were included for analysis. The follow-up period ranged from 12-25 months. The use of DEB was associated with an inferior acute gain in minimal luminal diameter (MLD) (0.36, 95% CI: 0.16-0.57mm), higher late loss in MLD (0.11, 0.02-0.19mm) and a higher binary restenosis rate at follow-up (risk ratio: 2.24, 1.49-3.37). No significant differences were noted in the overall incidence of the analysed clinical parameters between the two groups. When only the randomised controlled trials (RCT) were considered however, there was a strong trend towards higher target lesion revascularisation (TLR; 9.9% vs. 3.6%; RR: 2.5, p=0.07) and a significantly higher major adverse cardiovascular event (MACE) rate (15.7% vs. 8.8%; RR 1.78; p=0.02) with DEB. CONCLUSION While equipoise has been demonstrated in selected clinical outcomes between DEB and second generation DES in the treatment of ISR, the suboptimal angiographic outcome at follow-up and the higher TLR and MACE rates associated with DEB observed in the RCT are concerning. The results of the present analysis should be regarded as preliminary, although the generalised adoption of DEB in the treatment of ISR currently cannot be recommended.

Systematic review of percutaneous interventions for malignant pericardial effusion

The present systematic review assessed the safety and efficacy of percutaneous interventions for malignant pericardial effusion (MPE), with primary endpoint of recurrence of pericardial effusion. Electronic searches of six databases identified thirty-one studies, reporting outcomes following isolated pericardiocentesis (n=305), pericardiocentesis followed by extended catheter drainage (n=486), pericardial instillation of sclerosing agents (n=392) or percutaneous balloon pericardiotomy (PBP) (n=157). Isolated pericardiocentesis demonstrated a pooled recurrence rate of 38.3%. Pooled recurrence rates for extended catheter drainage, pericardial sclerosis and PBP were 12.1%, 10.8% and 10.3%, respectively. Procedure-related mortality ranged from 0.5–1.0% across the percutaneous interventions. Although isolated pericardiocentesis can safely deliver immediate symptomatic relief, subsequent catheter drainage or sclerotherapy are required to minimize recurrence. PBP has been shown to be highly effective and may be particularly useful in managing recurrent effusions. Ultimately, the choice of intervention must be based on the clinical status of patients, their underlying malignancy and the expertise available.

A meta-analysis of mitral valve repair versus replacement for ischemic mitral regurgitation

BACKGROUND The development of ischemic mitral regurgitation (IMR) portends a poor prognosis and is associated with adverse long-term outcomes. Although both mitral valve repair (MVr) and mitral valve replacement (MVR) have been performed in the surgical management of IMR, there remains uncertainty regarding the optimal approach. The aim of the present study was to meta-analyze these two procedures, with mortality as the primary endpoint. METHODS Seven databases were systematically searched for studies reporting peri-operative or late mortality following MVr and MVR for IMR. Data were independently extracted by two reviewers and meta-analyzed according to pre-defined study selection criteria and clinical endpoints. RESULTS Overall, 22 observational studies (n=3,815 patients) and one randomized controlled trial (n=251) were included. Meta-analysis demonstrated significantly reduced peri-operative mortality [relative risk (RR) 0.61; 95% confidence intervals (CI), 0.47-0.77; I(2)=0%; P<0.001] and late mortality (RR, 0.78; 95% CI, 0.67-0.92; I(2)=0%; P=0.002) following MVr. This finding was more pronounced in studies with longer follow-up beyond 3 years. At latest follow-up, recurrence of at least moderate mitral regurgitation (MR) was higher following MVr (RR, 5.21; 95% CI, 2.66-10.22; I(2)=46%; P<0.001) but the incidence of mitral valve re-operations were similar. CONCLUSIONS In the present meta-analysis, MVr was associated with reduced peri-operative and late mortality compared to MVR, despite an increased recurrence of at least moderate MR at follow-up. However, these findings must be considered within the context of the differing patient characteristics that may affect allocation to MVr or MVR. Larger prospective studies are warranted to further compare long-term survival and freedom from re-intervention.

Heart-type fatty acid binding protein in early diagnosis of myocardial infarction in the era of high-sensitivity troponin: a systematic review and meta-analysis.

Introduction Heart-type fatty acid binding protein (HT FABP) is an emerging biomarker of ischaemic myocardial necrosis. While previous studies have demonstrated its additive value when compared to contemporary troponin assays in the diagnosis of acute myocardial infarction (AMI), its utility in the era of high-sensitivity troponin (hsTn) assays remains undetermined. Methodology A systematic review and meta-analysis of relevant studies was performed comparing the diagnostic performance of HT FABP both alone and in conjunction with hsTn in the early diagnosis and exclusion of AMI. Results A systematic literature search yielded eight eligible studies including 3395 patients. Of these, 716 patients (21.1%) were eventually diagnosed with AMI. The pooled sensitivity and specificity for hsTn on admission was 82.5% (95% confidence interval [CI]: 79.8–85.0%) and 89.7% (95% CI: 88.7–90.6%), respectively, while the area under the curve (AUC) for the summary receiver operating characteristics (ROC) curve is 0.92 (SE 0.02). While the pooled specificity (84.6%, 95% CI: 83.2–85.9%) of admission HT FABP is similar to hsTn for the early diagnosis of AMI (P = 0.07), its pooled sensitivity (63.5%, 95% CI: 59.9–67.1%, P < 0.001) is significantly worse. Accordingly, the AUC of the summary ROC curve for HT FABP (0.79, SE 0.03) is inferior to hsTn (P < 0.0001). The addition of HT FABP to hsTn resulted in no improvement in the sensitivity (P = 0.058) and worsened the specificity (P = 0.001) in the early diagnosis of AMI compared to hsTn alone. Conclusion HT FABP does not appear to improve the diagnostic accuracy of hsTn, and consequently its routine use currently cannot not be recommended.

TCT-364 Radial vs Femoral Access for Coronary Angiography and Intervention in the Elderly (>75) - a Meta-analysis and Subgroup Analysis (All studies vs Octagenarian studies, N. America studies vs Rest of the World studies).

TCT-363 Patient Characteristics Influencing Physician Selection of Radial vs. Femoral Access in patients presenting emergently with STElevation Myocardial Infarction Jimmy Yee, James Higgins, Vishesh Kumar, Amornpol (Song) Anuwatworn, Shenjing Li, Alexander Pham, Julia Stys, Terezia Petraskova, Paul Thompson, Adam Stys, Marian Petrasko, Tomasz Stys University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota, United States; Interventional Cardiology, Sandro Pertini Hospital; CSI; Sanford School of Medicine of University of South Dakota, Sioux Falls, South Dakota, United States; Sioux Falls; MedStar Washington Hospital Center; Dallas VA Medical Center and UT Southwestern; UCLA, VA Greater Los Angeles Healthcare System; Dallas VA Medical Center and UT Southwestern; Sanford Cardiovascular Institute, Sioux Falls, South Dakota, United States; Sanford Cardiovascular Institute, Sioux falls, South Dakota, United States; Sanford Cardiovascular Institute, Sioux Falls, South Dakota, United States

Patent Foramen Ovale Influences the Presentation of Decompression Illness in SCUBA Divers

BACKGROUND Few have examined the influence of patent foramen ovale (PFO) on the phenotype of decompression illness (DCI) in affected divers. METHODOLOGY A retrospective review of our database was performed for 75 SCUBA divers over a 10-year period. RESULTS Overall 4,945 bubble studies were performed at our institution during the study period. Divers with DCI were more likely to have positive bubble studies than other indications (p<0.001). Major DCI was observed significantly more commonly in divers with PFO than those without (18/1,000 v.s. 3/1,000, p=0.02). Divers affected by DCI were also more likely to require a longer course of hyperbaric oxygen therapy (HBOT) if PFO was present (p=0.038). If the patient experienced one or more major DCI symptoms, the odds ratio of PFO being present on a transoesophageal echocardiogram was 3.2 (p=0.02) compared to those who reported no major DCI symptoms. CONCLUSION PFO is highly prevalent in selected SCUBA divers with DCI, and is associated with a more severe DCI phenotype and longer duration of HBOT. Patients with unexpected DCI with one or more major DCI symptoms should be offered PFO screening if they choose to continue diving, as it may have considerable prognostic and therapeutic implications.

Reply: High Intensity Interval versus Moderate Intensity Continuous Training in Patients with Coronary Artery Disease

We wish to thank Dr Cochrane for expressing an interest in our analysis of high intensity interval training (HIIT) versus moderate intensity continuous training (MICT) in patients with coronary artery disease (CAD) [1]. Our study [2] aimed to examine the relative merits of HIIT and MICT in these patients. We concluded that neither HIIT nor MICT has demonstrated clear superiority over the other, particularly in terms of patients’ long-term prognosis. We suggested that this was due to a lack of evidence in this domain, which is reflected by the current guidelines on secondary prevention, where level B and C evidence remain the sole basis for all current recommendations in this regard [3]. We reinforced this notion by indicating the need for large scale studies with mechanisms for long term follow-up, as similar studies (with follow-up up to 16 years) performed in healthy individuals have favoured vigorous over moderate intensity exercise in the prevention of CAD and improvement of the subjects’ risk factor profiles [4]. Further, HIIT has also been shown to have superior efficacy in improving vascular function in patients with a range of pre-existing cardiometabolic disorders [5]. While HIIT undertaken in isolationmay prove to be unsustainable over time for some, patients’ compliance with various exercise programs has not been thoroughly and comprehensively studied, nor have the factors that influence it. Logically, exercise regimens that are achievable with respect to patients’ age and underlying fitness are most likely to be continued. Indeed, instead of pitting one form of exercise against another, our study was really designed to differentiate and characterise them so that they can be tailored to the needs and physiological attributes of our patients in order to enhance their long-term adherence to the exercise programs. Finally, maximal aerobic capacity, often termed VO2max, remains a reasonable clinical and study endpoint in our

TCT-543 Calculation of Serial Index of Microvascular Resistance with Adjusted Wedge Pressure in Patients with Non-ST Elevation Acute Coronary Syndrome

Mean FFR in the RCA and LCA were comparable (0.78 versus 0.77; P1⁄40.58), but mean iFR was significantly higher in the RCA (0.90 versus 0.85; P<0.001). Moreover, the mean difference between iFR and FFR was significantly larger in the RCA (0.12 versus 0.08; P<0.001). Sensitivity of iFR in the RCA was significantly lower compared to the LCA (53.3% versus 79.1%; P<0.001). Specificity was significantly higher in the RCA compared to the LCA (94.3% versus 80.6%; P1⁄40.02).